Every finding on record at Regent Hospice, Inc.

Observed in Tracer Activities. The organization did not train staff for their assigned emergency response roles. In 4 of 10 personnel records reviewed: HR3, HR4, HR5, and HR6, there was no evidence of training completed for the staff's assigned emergency response roles in 2022. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 2 active patient records reviewed where there were no funeral/burial arrangements made, the hospice did not reassess the anticipated needs. Identified in RR#1, the Medical Social Worker (MSW) had documented in the initial comprehensive psychosocial assessment approximately eleven (11) weeks prior to the survey date that there were no funeral/burial arrangements made, and that the patient's decision maker was the Facility Bioethics committee. In two subsequent monthly MSW visits conducted, there was no reassessment of the patient's funeral/burial arrangements documented. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted with a skilled nurse, the patient's assessment was not conducted in accordance with the organizational policy #2-031.1 - Ongoing Comprehensive Assessment - 2. The nurse will assess the patient on each visit, for: F. Breath sounds, G. Skin Integrity; H. Bowel Sounds; elimination (urinary and bowel); and, J. Appetite/diet, nutritional status. Observed in HV#3 the Licensed Vocational Nurse assessed the patient's vital signs, and completed a pain assessment, but did not complete a thorough assessment through direct patient assessment, nor gathered through report with the patient's facility nurse. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. The organization did not include all services needed in the plan of care to meet the patients' and/or families' needs. In 2 of 4 active patient records reviewed, HV#1 and RR#1, the Medical Social Worker documented in the initial comprehensive psychosocial assessment that there were no funeral or burial plans, but did not include this need in the patients' individualized plans of care. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. The organization did not provide the patient with care according to the patient's individualized plan of care. Identified in 1 of 3 active patient records where hospice aide services were ordered, the visit frequency ordered was not followed. Reviewed in RR#1 the hospice aide frequency ordered at the start of care approximately eleven (11) weeks prior to the survey date was twice weekly. Identified in the record, the hospice aide made only one (1) visit the week following the start of care date. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the clinicians did not follow the organization's policy #9-014.2 - Bag Technique, 5) When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate . . .A. Stethoscope, bell and diagram - alcohol; D. Thermometer - soap and water . . .; E. Blood pressure cuff will be cleaned in accordance with the manufacturer's guide . . . Observed in HV#1, the Hospice Aide cleaned an electronic temporal thermometer, manual blood pressure cuff, and stethoscope with a Clorox bleach wipe. Observed in HV#3, the Licensed Vocational Nurse cleaned an electronic wrist blood pressure cuff and infrared thermometer with an unlabeled disinfecting wipe stored in a plastic sandwich size bag. This was reviewed and validated with the Administrator/Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted, the clinician did not follow the organization's bag technique policy #9-014.1 - Bag Technique, 2) The bag will be placed on a clean dry surface (i.e.., a surface that can be easily disinfected) in the car and in the home. Observed in HV#3, the Licensed Vocational Nurse (LVN) carried a nurse bag wrapped within a clear liner/bag into the nursing facility, and placed it on the patient's bedside table without first cleaning the table or using a barrier. Upon completion of the patient assessment, the LVN proceeded to the Nurses Station and placed the bag on the desk, again without a barrier, while he reviewed the patient's chart and medications. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Tracer Activities. The organization's education and training did not comply with law and regulation. In 4 of 10 personnel records reviewed: HR3, HR4, HR5 and HR 9, there was no evidence of OSHA/Blood Borne Pathogens training completed in 2022. This was reviewed and validated with the Administrator/DPCS.